Policy and Procedures Required in the State Operations Manual, Appendix PP

Policy and Procedures Required in the State Operations Manual, Appendix PP

Reflecting Draft F tags effective November 28, 2017

F-Tags / Policy/Procedure/Process /
563 / Visitation rights of residents-reasonable clinical and safety restrictions/visitor access
565 / Policy for how resident and family groups will be informed of facility policies and changes
572 / Share pertinent policies at admission
578 / Resident’s rights to formulate an advance directive, refuse medical/surgical treatment. The policy delineates the steps necessary to promote these rights
580 / Notification of changes: accident with injury, change in status, need to alter treatment, decision to transfer, room or roommate change, change in rights
583 / Protecting resident privacy and confidentiality. (Social media, photographs)
585 / Grievance Policy
600 / Abuse-policy to identify when, how and by whom determination of capacity to consent to a sexual contact will be made and where this document will be recorded.
Prohibit, Identify, report abuse
Policy for Abuse prevention training
Policy r/t aspects of Quality of Life and/or care, Advance directive, intimacy and relationships
Policies re: care & services per current standards of practice
602 / Policy for investigation of drug diversion as misappropriation of resident property
603 / Secured locked units-including criteria for placement
Policy for placement of residents for transmission precautions related to seclusion in the room
604 / Policy re: wo can initiate emergency restraint
606 / Screening procedures prior to employment
607 / Prohibit and prevent abuse, neglect and exploitation and misappropriation
Policies to investigate allegations
Policy and procedure for training new and existing NH staff and in-service training for NA
Prevention prohibit all types of abuse
Written procedures to assist staff in identifying abuse, neglect
Procedures for investigation
Written procedures for protecting residents
Written procedures for reporting allegations
608 / Ensure reporting of crimes-including examples of crimes
Written procedure notifying covered individuals annually of their obligation
P&P promote culture of safety and open communication in the work environment
Posting a conspicuous notice of employee rights
Prohibiting and preventing retaliation
620 / Admissions policy-stipulate limited conditions for transfer or discharge
For room changes
P&P to safeguard resident’s personal property
Process to document high-value personal property
621 / Equal access to care and identical policies regarding transfer regardless of payment
625 / Policy holding resident bed during periods of absence
626 / Policy permitting resident to return to the facility
639 / Policy for electronic storage of MDS with hard to copy to surveyors upon request
642 / Policy for electronic signatures- computer security measures
646 / Process to notify appropriate state mental health or intellectual disability authority when a resident with a Level II PASARR has a significant change in mental or physical status
660 / Process for discharge
Against Medical Advice
678 / CPR
Systems and processes for Adequate # of staff present at all times who are properly trained
Procedure to document a resident’s choices regarding issues like CPR
Code status
684 / Care policies that are consistent with current professional standards of practice not only pain management about symptom control, but for assessing resident’s physical, intellectual, emotional, social, and spiritual needs as appropriate.
Policies must identify the ongoing collaboration and communication process between the nursing home and hospice
686 / Skin Integrity
Treatment protocols with Medical Director approval
688 / Resident care policies restorative/rehab tx/services, also equipment use, cleaning and storage
689 / Safety policies with input from staff
Wandering/elopement
Smoking
Plan to locate missing resident
Disaster and emergency preparedness
690 / Catheter care and services
Policy obtaining urine for culture
693 / P&P Monitoring feeding tube
Care of feeding tube
Feeding tube replacement
Complications
694 / IV’s - Policies for preparation, insertion administration, maintenance and discontinuance of IV as well as prevention of infection at site to extent possible.
Care and use of all IV equipment, such a pumps, tubing, syringes, fluids
695 / Respiratory-P&P for respiratory care and services prior to admission of a resident requiring specific types of respiratory care and services
698 / Dialysis-monitoring of access site
Types of dialysis that are provided in NH are consistent with current standards
Cleaning policies if dialysis in-house
Emergency meds for in-house dialysis
700 / Process for scheduling for routine maintenance of beds and bed rails correct use
711 / Facility practice of progress notes written, signed and dated at each physician visit in a chart of HER
Policy for standing orders for influenza and pneumococcal vaccine
Use of rubber stamp signatures
712 / Policy if the resident leaves the grounds for medical care – (expectation that visit occurs at the facility)
Policy for NP to conduct required visits
713 / Agreement with another MD to provide physician services in the absence of the attending physician
714 / Physician delegation of tasks to NP, CS, PA
715 / Policy allowing physician to delegate the task of writing orders to qualified dietitian and qualified therapist-according to stat e law - how does the facility ensure the physician supervision of individuals performs these tasks
755 / Policy for consulting pharmacist
System of records of receipt and disposition of all controlled drugs
Procedure acquiring controlled drugs process for medication orders, receiving and administering medications including transfer orders, admission orders, telephone orders order renewals and the MAR
Policy for reporting controlled med count discrepancy
756 / Drug Regimen Review –time frames for the different steps in the process and steps the pharmacist must take when irregularities require urgent action to protect the resident
MRR for residents who are anticipated to stay < 30 days
MRR for residents who experience an acute change of condition
Procedure to resolve situation where physician does not concur with or take action on identified irregularities
Procedure to resolve situation where the attending physician is the Medical Director
758 / Med Management
Stop orders for certain meds
Policy for continuing antibiotic beyond recommended clinical guideline
759 / Policy for checking feeding tube placement before med administration
Policy for medication dosing schedules
Policy for identification of residents prior to med admin
760 / Policy or system for identification of resident system to limit who has security access and when access is used for controlled meds (scheduled II-IV)
Procedure for control and safe storage of meds for those who can self-administer medication
Procedures that address and monitor safe storage and handling of medications
761 / Policies for quality and timeliness of Lab services
770 / Labs-P&P for the quality and timeliness of services whether services are provided by the facility or an outside service
771 / Prevent transfusion reactions
Positive ID of blood components
773 / P&P defining categories that are considered outside clinical reference ranges for lab values, the urgency of reporting values and a process for monitoring the effectiveness of communication
774 / Procedure for making transportation arrangements to and from source of service
777 / Radiology-procedure for defining categories where follow-up is required, the urgency of reporting specific concerns and a process for monitoring the effectiveness of communication to ensure that communication was received and delegation by the ordering provider
790 / Dental Services-identification of circumstances when the loss or damage of dentures is the facility’s responsibility and may not charge a resident
811 / Paid Feeding Assistants-Knowledge on how to obtain assistance in an emergency
Process for verification of state approved training course
812 / Food receiving and storage-
Maintaining and harvesting the gardens, including ensuring manufacturer’s instructions are followed if any pesticides, fertilizers or other topical or root-based plant preparations are applied
Process for monitoring temperatures for refrigerators
P&P to prevent the spread of foodborne illness and minimize food storage, preparation and handling practices that could cause food contamination and could compromise food and safety
Cleaning schedule for kitchen and food service equipment
Pot luck events
Food from visitors
Sufficient staffing
No sick employees to work
813 / Use and storage of personal food items-give to families and residents
Personal refrigerator
Food brought to residents by family and other visitors
Staff assisting residents in accessing and consuming the food
837 / Governing Body-
Process by which administrator reports to governing body, the method of communication, how the governing body responds back
How the administrator is held accountable and reports information
Active governing body that is responsible for establishing and implementing policies regarding management of the facility
840 / Timeliness of outside resources
841 / Medical Director-
Job description or policy for how Med Director will carry out responsibilities to effectively implement resident care policies and coordinate medical care
If the medical director is also an attending physician there should be a process to ensure there are no concerns with the individual’s performance as a physician-facility must have a process how to address this situation.
Be involved in corporate policies and facility unique policy development
Show participation in policy development
System development to monitor performance of health care practitioners including mechanism for communicating and resolving issues r/t medical care and other licensed practitioners act within scope of practice
842 / Electronic Signatures-
P&P maintaining confidentiality of resident records
Storage including archiving
843 / Emergency resident transfer policy
846 / Facility Closure-P&P must be in place at all time
Administrator’s duties and responsibilities
Communication to receiving entities
Roles and responsibilities of owners
Provisions of ongoing operations during closure process
Interview of residents and their legal for goals, preferences, offering community options, providing residents with information, access of another entity(s)
849 / Hospice-written agreement
Orientation of Hospice staff to facility policies
865 / QAPI
866 / Program feedback, data systems and monitoring
Systems to obtain and use feedback
Maintenance of effective system to identify, collect and use data and information
Methodology and frequency for development, monitoring and evaluation of data
867 / Use of a systematic approach to determine underlying causes of problems impacting larger systems
Development of corrective actions that will be designed to effect change at the system level to prevent quality of care, quality of life or safety problems
How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained
868 / If Medical Director not present at QAA the process of communication of the content of the meeting to the Medical Director with his/her acknowledgement of the information
880 / Infection Control
System of surveillance
When and to whom possible incidents of communicable disease or infections should be reported
Standard and transmission-based precautions
When and how isolation should be used
The circumstances under which the facility must prohibit employees with a communicable disease
Hand hygiene procedures to be followed
P&P safe use of insulin pens
Laundry Services-including off-site
881 / Antibiotic Stewardship
883 / Influenza and pneumococcal immunizations
895 / Phase 3-compliance and ethics program
908 / P&P for inspection of equipment, mattresses
922 / Procedure to ensure water is available to essential areas when there is a loss of normal water supply
926 / Smoking policies
945 / Train about Infection control policies

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